Tricuspid and pulmonary valve disease

April 8th, 2020 / By Rebecca Caux-Harry

We’re all living through uncertain times, and like most coding professionals, I’m focused on learning as much as I can about the new guidelines for COVID-19 documentation and coding. It can be helpful to take a break though, so I decided l needed to blog about something other than the pandemic. Wow, that’s a word I never thought I would use related to a current event.

The past few blogs I’ve written have been about reviewing documentation and selecting the appropriate ICD-10-CM codes to correctly report aortic and mitral valve disease. Since there are four valves in the heart, I’ll conclude this series with review of the two valves which live in the right heart.

The tricuspid valve controls flow of deoxygenated blood between the right atrium and the right ventricle. As the name implies, there are three leaflets in this valve. The pulmonary valve, also containing three leaflets, controls the flow of deoxygenated blood from the right ventricle into the pulmonary artery, which bifurcates and pushes the blood to each lung for reoxygenation.

As with the aortic and mitral valves, these two valves can also have congenital malformations or even be missing (atresia) depending on the severity of the congenital defect. The two types of disease, whether congenital or acquired later in life are stenosis and regurgitation. With valve stenosis, the leaflets don’t open completely to allow the blood to flow through the valve unimpeded. Regurgitation, or insufficiency, is when the leaflets don’t coapt completely, allowing blood to leak back through the valve. Both types of disease can create a build-up of pressure in the heart chambers as blood flow is impeded through the heart chambers. 

In the ICD-10-CM book, when looking up disease, tricuspid, we are given two choices: I07.9 and I36.9 for nonrheumatic disease.  When I look at the INCLUDES language associated with I07, it states “rheumatic tricuspid valve diseases specified as rheumatic or unspecified.”  So, without specific nonrheumatic language, we are to assume the disease is rheumatic.  However, when looking up disease, pulmonary, valve, our first choice is I37.9 then rheumatic I09.89.  Oddly, the descriptor for this code is “other specified rheumatic heart diseases” with example language of “rheumatic disease of pulmonary valve.”

These are the codes to select when documentation is poor. Ideal documentation would include whether the disease is stenosis or regurgitation or both, whether the disease is rheumatic or nonrheumatic and whether it is congenital or not. Without specifying language, we assume the disease is acquired rather than congenital. We also need to know if additional valves are diseased. 

So, for code selection we have the following groups:

Tricuspid valve

I07.0 Rheumatic tricuspid stenosis (I36.0 Nonrheumatic tricuspid stenosis)

I07.1 Rheumatic tricuspid insufficiency (I36.1 Nonrheumatic tricuspid insufficiency)

I07.2 Rheumatic tricuspid stenosis and insufficiency (I36.2 I36.0 Nonrheumatic tricuspid stenosis with insufficiency)

I07.8 Other rheumatic tricuspid valve diseases (I36.8 Other Nonrheumatic tricuspid valve disorders)

I07.9 Rheumatic tricuspid valve disease, unspecified (I36.9 Nonrheumatic tricuspid valve disorders, unspecified)

Pulmonary (Pulmonic) valve

I09.89 Other specified rheumatic heart disease

I37.0 Nonrheumatic pulmonary valve stenosis

I37.1 Nonrheumatic pulmonary valve insufficiency

I37.2 Nonrheumatic pulmonary valve stenosis with insufficiency

I37.8 Other Nonrheumatic pulmonary valve disorders

I37.9 9 Nonrheumatic pulmonary valve disorders, unspecified

Notice we only have one rheumatic pulmonary valve disease code (the others are all specified as nonrheumatic). Additionally, we don’t have ICD-10-CM direction to assume the disease is rheumatic unless otherwise specified.

If the disease is documented as congenital, our codes come for Chapter 17. They are:

Q22.0 Pulmonary valve atresia

Q22.1 Congenital pulmonary valve stenosis

Q22.2 Congenital pulmonary valve insufficiency

Q22.3 Other congenital malformations of pulmonary valve

Q22.4 Congenital tricuspid atresia

Q22.5 Ebstein’s anomaly

Q22.8 Other congenital malformations of tricuspid valve

Q22.9 Congenital malformation of tricuspid valve, unspecified

When multiple valves are involved, we are directed to the rheumatic valve disease section, whether documented or not.  We have the following codes:

I08.0 Rheumatic disorders of both mitral and aortic valves

I08.1 Rheumatic disorders of both mitral and tricuspid valves

I08.2 Rheumatic disorders of both aortic and tricuspid valves

I08.3 Rheumatic disorders of both mitral, aortic and tricuspid valves

I08.8 Other rheumatic multiple valve diseases

I08.9 Rheumatic multiple valve disease, unspecified

So, when coding valve disease we need to know which valve, the type of disease, whether congenital or acquired, rheumatic or not and whether any other valves are also diseased. Remember to always review the Includes and Excludes notes associated with each grouping of codes as they are not consistent between the groupings of valve disease codes.

Good luck coding!

Rebecca Caux-Harry, CPC, is a professional fee coding specialist with 3M Health Information Systems.